MEDICAL REPORT FORM

Rev: 01
Date: 19th Nov.2020
SOPM-FORM-44

(MLC Regulation A4.1)

SECTION(A) To be completed by Vessel & submitted to
RVOS_HSE@RawabiVallianz.com & RVOS_ RVOS_Crewing@RawabiVallianz.com , RVOS_operations@rawabivallianz.com
SHIP INFORMATION & LOCATION
Name of Vessel: Rawabi 15 Medical Report No.(00X/YYYY): 002/2023
Ship Manager: Rvos Location of Vessel: At Sea
Date of Medical Report April 17, 2023 Time of Medical Report: 13:35
Date of Arrival / Next Port Call (MM/DD/YYYY): 17-Apr-23
PARTICULARS OF PATIENT
Name as in Passport: Sex: Male ☒ Female ☐
Date of Birth (MM/DD/YYYY): 12-Nov-2023 Nationality: Azerbaijan Rank / Position: Chief Officer
Seafarer Passport Number: C00320196 Date Sign-on vessel: 13-Apr-2023
Hour & date when taken off work: Not Taken
INJURY OF ILLNESS
16:00 / 15-Apr-2023
Hour and date of injury or onset of illness:

Hour and date of first examination / 16:30 / 15-Apr-2023

treatment onboard:
Location on board ship where injury Abu Safah Oil Field
occurred:
Circumstances of illness / injury: Pain In Throat. Cought Cold
Pain In Throat. Cought Cold
Symptoms / Condition:

Pain In Throat. Cought Cold

Findings of physical examination:

TREATMENT GIVEN ON BOARD

Given Parastamol 500 mg (Panadol Extra & Nosal Drops)

Is this injury of illness due to an accident? YES ☐ / NO ☒

If yes, please submit incident notification form (SOPM-FORM-63 Written Incident Notification Rev 1)

SECTION(B) To be completed by Office

SOPM-FORM-44 Revision: 01 Page 1 of 2
MEDICAL REPORT FORM
Rev: 01
Date: 19th Nov.2020
SOPM-FORM-44

TELE-MEDICAL CONSULTATION
Hour and date of initial contact:      
Radio ☐ Telephone ☐ Fax ☐ Other ☒
Mode of communication (radio, telephone,
fax, other) If Other, please specify:      

Insurance informed? YES ☐ / NO ☐

Surname and first name of tele-medical      
consultant or name of medical company:
Details of tele-medical advice given:      
     
Follow-up action:

CLINICAL CONSULTATION
Date of consultation:      

Doctor Diagnosis:      

Place of consultation: Clinic / hospital      

Block / Ward / Room / Bed
Clinical Treatment given or examination:      
Clinical Treatment terminated or follow up
required: Ops, MRI Scan, Ct Scan etc.      
Patient unfit for work from: ___ to ___
     
Hour and date when returned to work:

Note: Attach all relevant medical reports to this report form.

SOPM-FORM-44 Revision: 01 Page 2 of 2